Virtual measurement tool for minimally invasive surgery

ABSTRACT

Robotic and/or measurement devices, systems, and methods for telesurgical and other applications employ input devices operatively coupled to tools so as to allow a system user to manipulate tissues and other structures being measured. The system may make use of three dimensional position information from stereoscopic images. Two or more discrete points can be designated in three dimensions so as to provide a cumulative length along a straight or curving structure, an area measurement, a volume measurement, or the like. The discrete points may be identified by a single surgical tool or by distances separating two or more surgical tools, with the user optionally measuring a structure longer than a field of view of the stereoscopic image capture device by walking a pair of tools “hand-over-hand” along the structure. By allowing the system user to interact with the tissues while designating the tissue locations, and by employing imaging data to determine the measurements, the measurement accuracy and ease of measurement may be enhanced.

CROSS-REFERENCE TO RELATED APPLICATIONS

The present application is related to U.S. patent application Ser. No. 12/428,691 (filed Apr. 23, 2009), Ser. No. 12/465,029 (filed May 13, 2009), and ______ (filed concurrently) entitled “Virtual Measurement Tool For Minimally Invasive Surgery” (Attorney Docket No. ISRG 01931/US), the full disclosures of which are incorporated herein by reference.

STATEMENT AS TO RIGHTS TO INVENTIONS MADE UNDER FEDERALLY SPONSORED RESEARCH OR DEVELOPMENT

Not applicable.

REFERENCE TO A “SEQUENCE LISTING,” A TABLE, OR A COMPUTER PROGRAM LISTING APPENDIX SUBMITTED ON A COMPACT DISK

Not Applicable.

BACKGROUND

The present invention is generally related to improved robotic and/or measurement devices, systems, and methods. An exemplary embodiment provides a robotic surgical system which makes use of a combination of telemanipulation of a robotic tool together with stereoscopic image processing to input and designate discrete three-dimensional (3-D) point locations along the tissue (or other structure), continuous 3-D contours, and other 3-D structural information so as to obtain length measurements, area measurements, volume measurements, or the like.

Minimally-invasive surgical techniques are aimed at reducing the amount of extraneous tissue that is damaged during diagnostic or surgical procedures, thereby reducing patient recovery time, discomfort, and collateral tissue damage. As a consequence, the average length of a hospital stay for standard surgery may be shortened significantly using minimally-invasive surgical techniques. Also, patient recovery times, patient discomfort, surgical side effects, and time away from work may also be reduced with minimally-invasive surgery.

Endoscopy is a well known form of minimally-invasive surgery, and a common form of endoscopy is laparoscopy, which is minimally-invasive inspection and surgery inside the abdominal cavity. In standard laparoscopic surgery, a patient's abdomen is insufflated with gas and cannula sleeves are passed through small (approximately ½ inch or less) incisions to provide entry ports for laparoscopic instruments.

Laparoscopic surgical instruments generally include a laparoscope or an endoscope (for viewing the surgical field), and working tools. The working tools are similar to those used in conventional open surgery, except that the working end or end effector of each tool is separated from its handle by an elongate shaft. The end effector or working part of the surgical instrument can manipulate or treat tissue, and may (for example) include clamps, graspers, scissors, staplers, image capture lenses, or needle holders.

To perform surgical procedures, the surgeon passes the working tools or instruments through cannula sleeves to an internal surgical site and manipulates the tools or instruments from outside the abdomen. The surgeon views the procedure by means of a monitor that displays an image of the surgical site taken from the laparoscope. Similar endoscopic techniques are employed in, e.g., arthroscopy, retroperitoneoscopy, pelviscopy, nephroscopy, cystoscopy, cisternoscopy, sinoscopy, hysteroscopy, urethroscopy, and the like.

Minimally-invasive telesurgical robotic systems are being developed to increase a surgeon's dexterity when working within an internal surgical site, and optionally to allow a surgeon to operate on a patient from a remote location. In a telesurgery system, the surgeon is often provided with an image of the surgical site at a control console. While viewing a 3-D image of the surgical site on a suitable viewer or display, the surgeon performs the surgical procedures on the patient by manipulating master input or control devices of the control console. Each of the master input devices controls the motion of a servomechanically operated surgical instrument. During the surgical procedure, the telesurgical system can provide mechanical actuation and control of a variety of surgical instruments or tools having end effectors that perform various functions for the surgeon, e.g., holding or driving a needle, grasping a blood vessel, dissecting tissue, or the like, in response to manipulation of the master input devices.

While the new telesurgical robotic systems have tremendous promise for extending the capabilities of surgeons to perform therapies with less trauma to the patient, as with many successes, still further improvements would be desirable. For example, known robotic systems often rely on joint position information from sensors associated with each of the joints of the robotic linkage to calculate end effector movement demands, locations, and the like. While such joint-based information provides sufficiently accurate relative movements of the end effector for most telesurgical purposes, the absolute location of the surgical tool determined using this joint-based data may not be precise enough for all purposes. In particular, there are times when it would be advantageous to acquire tissue measurement information using the robotic surgical system, and some improvement over the accuracy provided by the joint-based data may be beneficial for such measurements.

In light of the above, it would be desirable to provide improved robotic and/or measurement systems for surgery and other applications. It would be particularly advantageous if these improvements allowed the physician to both interact with and measure tissues, ideally with the measurements comprising three dimensional measurements with accuracies beyond those easily provided using joint-based data alone.

SUMMARY

Aspects of the present invention generally provide improved robotic and/or measurement devices, systems, and methods. Embodiments of the invention may find use in telesurgical therapies through minimally invasive apertures such as an endoscopic cannula sleeve, a natural orifice, or the like. Such embodiments may employ telesurgical input devices operatively coupled to surgical tools so as to allow a system user to manipulate and otherwise interact with the tissues being measured. Rather than merely relying on joint-based data, the system may make use of three-dimensional (3-D) position information garnered from stereoscopic images, with the images also being presented to the system user. In addition to 3-D positional offsets between two or more discrete points on the tissue, the system may also allow the user to identify an effectively continuous curving line of positions along a tissue of interest. The system can then determine a length measurement of a 3-D line segment, a poly-line measurement of cumulative lengths along a straight or curving tissue, a measurement of the area within a tissue structure, a tissue volume measurement, an aspect ratio, or the like. The discrete points may be identified by a single surgical tool or by a separation between two or more surgical tools, with the user optionally measuring the length of a tissue structure (even a structure longer than a field of view of the stereoscopic image capture device or which is partially obscured) by walking a pair of tools “hand-over-hand” along the tissue structure, optionally while straightening or stretching the tissue structure. By allowing the system user to interact with the tissues while identifying the tissue locations to be measured, and by employing imaging data (optionally in combination with joint-based data) to determine the measurements, the measurement accuracy and ease of tissue measurements can be significantly enhanced, particularly when working with tissues that are at least partially obscured.

In a first aspect, the invention provides a method for measuring tissue. The method comprises acquiring an image of the tissues so as to generate corresponding image data. A first tissue location is indicated with a first robotic tool. A first graphical indicator is superimposed on the image of the tissue at the first location. A measurement is generated between the first graphical indicator and a second tissue location using the image data.

The acquired image of the tissue will typically include both left and right stereoscopic images shown on a stereoscopic display to the system user. The first tool may be guided to the first tissue location by the system user with reference to those stereoscopic images. The tool and display are typically included within a telesurgical system. The system user will often input at least one tissue designation command when the tissue locations are engaged or otherwise indicated by a robotic tool. A stereoscopic image capture device will often transmit the stereoscopic imaging data to the stereoscopic display. The graphical indicator may include a 3-D indicator that is superimposed on the stereoscopic images of the tissue so as to appear coincident in three dimensions with the first location. The system can determine the first location of the superimposed indicator using stereoscopic imaging data associated with the first tool.

The first tool may be used to indicate both the first location and the second tissue location, with the tissue locations being indicated sequentially. Alternatively, a second robotic tool may indicate the second tissue location, with the second tissue location being engaged simultaneously with the first tissue location. The tissue locations can be indicated by engaging or palpating the tissue with the tool, with the tool optionally manipulating the tissue so as to straighten or stretch the tissue, or so as to otherwise move into a measurement configuration. In alternative embodiments, the tool may indicate the tissue location by bring the tool into proximity of the location without actually touching the tool to the tissue surface. The three dimensional location of the tissue can be determined from stereoscopic imaging data or the like, and the graphical indicator can then be snapped from the tool to the tissue surface.

The image may encompass a plurality of tools, including multiple robotic tools. A graphical tool measurement marker may be superimposed on the display coincident with the first tool while guiding the first tool to the first tissue location using the image. This can avoid confusion regarding which tool is to be used for a measurement, and may also enhance accuracy by identifying the measurement data point on the tool to the system user. A moving line that extends between the first and second locations may be superimposed on the display while guiding the first tool to the first location, with the moving line giving the appearance of a stretching line or rubber band during tool manipulation. One or more additional tissue locations may also be robotically identified, with the measurement including a 3-D offset distance between a sequential pair of the tissue locations. A cumulative total of the offset distances between sequential pairs may also be provided, so as to allow a total length of measurement along a contour or plurality of contiguous line segments.

In some embodiments, the tissue locations may be alternatingly indicated by the first tool and a second tool. In such embodiments, the tools may optionally each grasp the tissue at the associated locations in jaws of the tools. The distances between the locations grasped by the tools may be summed so as to measure a hand-over-hand length along the grasped tissue structure. The tissue locations may be designated by actuation of the jaws (optionally by opening of the jaws, closing of the jaws, or the like). Where a single tool is used to designate a sequential series of tissue locations, the command to designate a tissue location may be input by the user by actuating a handle of the system with the same type of actuation used to open and close jaws. Alternative tissue designation commands may also be employed, including additional input buttons, foot pedal inputs, pull down command menus, verbal input commands, or the like, and other input commands may be employed to de-designate or remove previously input tissue locations.

In many embodiments, the user may robotically engage or otherwise indicate the second location, and in many cases a plurality of additional tissue locations. The locations and/or an input from the system user may define an enclosed area, with the measurement including a measurement of that area. In some embodiments, the tissue locations may comprise discreetly designated locations bordering the area. Alternatively, the tissue locations may comprise a substantially continuous line bordering the area, such as by identifying tool locations at closely-spaced time intervals, at desired separation distances from the prior locations, or the like. Regardless, a center of the area may be identified and the area calculated by summing areas of triangles defined between the center and the tissue locations along the border. An aspect ratio defined by the locations may also be determined, such as by determining a width of an area relative to a length of the area, a width between two tissue features relative to a length, or the like.

Where the tissue comprises a physiologically moving tissue (such as a beating heart or the like) a stereoscopic video image may be frozen for measurement once the first tool indicates the first tissue location. The second tissue location can then be indicated by positioning a three dimensional graphical indicator superimposed on the still or frozen stereoscopic image so as indicate the second tissue location.

In another aspect, the invention provides a system for measuring tissue. The system comprises an image capture device oriented toward a surgical site. The image capture device, during use, generates image data corresponding to an image of the tissue at the surgical site. A display is coupled to the image capture device so as to show the image to a system user. A first robotic tool is provided, along with an input for designating tissue locations indicated by the first tool. A processor couples the input to the display so as to superimpose a first graphical indicator on the image of the tissue at a first designated tissue location. The processor also determines a measurement between the first graphical indicator and a second tissue location using the image data.

In yet another aspect, the invention provides a robotic system for measuring physiologically moving tissue. The system comprises a stereoscopic image capture device oriented toward a surgical site. In use, the image capture device generates video image data corresponding to an image of the tissue at the surgical site. A display is coupled to the image capture device so as to show the image to a system user. A three dimensional input designates tissue locations, and a processor couples the input to the display so as to position a three dimensional graphical indicator superimposed on a frozen stereoscopic image of the tissue when a first tissue location is designated. A measurement between the graphical indicator and the first tissue location is determined by the processor.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a plan view of a minimally-invasive robotic surgery system being used to perform a surgery, in accordance with embodiments of the invention.

FIG. 2 is a front view of a surgeon's control console for a robotic surgery system.

FIG. 3 is a front view of a robotic-surgery system vision cart.

FIG. 4 diagrammatically illustrates data processing structures of the robotic surgery system of FIG. 1.

FIG. 5A is a front view of a patient side cart (surgical robot) of a robotic surgery system.

FIGS. 5B and 5C are respective front views of an 8 mm shaft robotic surgery tool and a 5 mm shaft robotic surgery tool.

FIG. 6 schematically illustrates steps included in a method for measuring tissue using the system of FIG. 1.

FIG. 7 is a flowchart for contour measurement, and specifically for designating a plurality of tissue or other structure locations.

FIG. 8 is a class diagram of contour measurement tools making use of tissue or other structure locations.

FIG. 9 is a flowchart for an effectively continuous sampling mode to produce regularly spaced locations or samples according to optional embodiments of the invention.

FIGS. 10A and 10B are class diagrams for area or container computation and display.

FIG. 11 is a flowchart illustrating software for hand-over-hand tissue or other location designation for measurement.

FIG. 12 is a screenshot of a robotic surgical tool image on which designated locations and a stretch line are superimposed.

FIG. 13 is a simplified schematic illustration of a single robotic surgical tool designating a contour or continuous series of line segments between tissue locations for cumulative length measurement.

FIG. 14 is a screen shot of a tool being used to measure a circumference and area of a tissue structure.

FIG. 15A is a simplified schematic diagram of two surgical robotic tools being used to measure, with a hand-over-hand approach, a length of a flexible tissue structure.

FIG. 15B is a screen shot of two robotic surgical tools obtaining a hand-over-hand measurement.

DETAILED DESCRIPTION

Aspects of the present invention generally provides improved robotic and/or measurement devices, systems, and methods, particularly for telesurgery and other medical robotic applications. Embodiments of the present invention may find their most immediate use for measurement of tissues and other structures located at an internal surgical site accessed through one or more minimally invasive apertures (such as a cannula or natural orifice). Work in connection with the present invention has indicated that measurement at such a site may be enhanced by engaging and/or manipulating the tissues to be measured using a robotic surgical tool. While robotic manipulations can be performed with very good precision using joint-based data from the robotic linkage to calculate movement commands, measurement accuracy within an internal surgical site may be enhanced by employing image processing of stereoscopic imaging data to help determine the locations of tissue and/or robotic surgical tools within the internal surgical site. By superimposing appropriate indicia on the stereoscopic images presented to a system user, the user can accurately designate tissue or other structure locations and measure contours (including smoothly curving contours and/or series of line segments) in three-dimensional (3-D) space so as to determine lengths, areas, volumes, and the like.

FIG. 1 is a plan view illustration of a Minimally-Invasive Robotic Surgical (MIRS) system 10, typically used for performing a minimally-invasive diagnostic or surgical procedure on a Patient 12 who is lying on an operating table 14. The system can include a surgeon's console 16 for use by a Surgeon 18 during the procedure. One or more Assistants 20 may also participate in the procedure. The MIRS system 10 can further include a patient side cart 22 (surgical robot), and a vision cart 24. The patient side cart 22 includes manipulators 23, which can manipulate at least one removably coupled instrument or tool assembly 26 (hereinafter simply referred to as a “tool”) through a minimally invasive incision in the body of the Patient 12 while the Surgeon 18 views the surgical site through the console 16. An image of the surgical site can be obtained by an endoscope 28, such as a stereoscopic endoscope, which can be manipulated by another manipulator 23 of the patient side cart 22 so as to position and orient the endoscope 28. The vision cart 24 can be used to process the images of the surgical site from the endoscope 28 for subsequent display to the Surgeon 18 through the surgeon's console 16. The number of surgical tools 26 used at one time will generally depend on the diagnostic or surgical procedure and the space constraints within the operating room among other factors. Optionally, more than one Surgeon's console may be provided, particularly when three or more tools will be used, thereby allowing two surgeon to collaborate, transfer control of instruments, and the like as more fully explained in U.S. Pat. No. 6,659,939 (filed Nov. 3, 1999), the disclosure of which is incorporated herein by reference. If it is necessary to change one or more of the tools 26 being used during a procedure, an Assistant 20 may remove the tool 26 no longer being used at the time from the patient side cart 22 and replace it with another tool 26 from a tray 30 in the operating room.

FIG. 2 is a front side view of the surgeon's console 16. The surgeon's console 16 includes a left eye display 32 and a right eye display 34 for presenting the Surgeon 18 with a coordinated stereo view of the surgical site that enables depth perception. The console 16 further includes one or more control devices 36 (masters), which in turn cause the patient side cart 22 (shown in FIG. 1) to manipulate one or more tools (slaves). Preferably, control devices 36 will provide the same degrees of freedom as their associated tools 26 (shown in FIG. 1) so as to provide the Surgeon with telepresence—the perception that the control devices 36 are integral with the tools 26 so that the Surgeon has a strong sense of directly controlling the tools 26. To this end, position, force, and tactile feedback sensors (not shown) are optionally employed to transmit position, force, and tactile sensations from the tools 26 back to the Surgeon's hands through the control devices 36.

The surgeon's console 16 is usually located in the same room as the patient so that the Surgeon may directly monitor the procedure, be physically present if necessary, and speak to an Assistant directly rather than over the telephone or other communication medium. However, it will be understood that the Surgeon can be located in a different room, a different building, or other remote location from the Patient, thus allowing for remote surgical procedures.

FIG. 3 is a front view of a vision cart 24. Vision cart 24 can be coupled with the endoscope 28 and can include a processor to process captured images for subsequent display, such as to a Surgeon on the surgeon's console, or on any other suitable display located locally and/or remotely. For example, where a stereoscopic endoscope is used, the vision cart 24 can process the captured images so as to present the Surgeon with coordinated stereo images of the surgical site. Such coordination can include alignment between the opposing images and can include adjusting the stereo working distance of the stereoscopic endoscope. As another example, image processing can include the use of previously determined camera calibration parameters so as to compensate for imaging errors of the image capture device, such as optical aberrations. Exemplary details of some of the possible image processing that can used are described in numerous patents and patent applications assigned to Intuitive Surgical, Inc. including, for example in U.S. Pat. No. 7,277,120 (filed Mar. 7, 2004), the full disclosure of which is incorporated herein by reference.

FIG. 4 diagrammatically illustrates a robotic surgery system 50 (such as MIRS system 10 of FIG. 1), showing communication paths between components. As discussed above, sSurgeon's console 52 (such as surgeon's console 16 in FIG. 1) can be used by a Surgeon to control a patient side cart (surgical robot) 54 (such as patient side cart 22 in FIG. 1) during a minimally-invasive procedure. The patient side cart 54 can use an imaging device, such as a stereoscopic endoscope, to capture images of the procedure site and output the captured images to a vision cart 56 (such as vision cart 24 in FIG. 1). Vision cart 56 can process the captured images in a variety of ways prior to any subsequent display. Alternatively, the patient side cart 54 can output the captured images for processing outside the vision cart 56. For example, the patient side cart 54 can output the captured images to a processor 58, which can be used to process the captured images. The images can also be processed by a combination the vision cart 56 and the processor 58, which can be coupled together so as to process the captured images jointly, sequentially, and/or combinations thereof. One or more separate displays 60 can also be coupled with the processor 58 and/or the vision cart 56 for local and/or remote display of images, such as images of the procedure site, or any other related images.

Each of the processors described herein will typically include tangible media (e.g., one or more locations and/or storage types) 59 embodying computer-readable instructions or software for implementing some or all of the method steps described herein. Tangible media 59 may comprise an optical recording media such as a compact disk or digital video disk, a magnetic recording media such as a hard disk drive, a floppy disk, a backup tape, or the like, a memory such as a read-only memory, a random access memory, a non-volatile memory, a memory stick, or the like. The software or code stored in tangible media 59 may be transmitted to the processor via the tangible recording media, an internet or other network system, a wireless signal transmission, or the like. While schematically shown in FIG. 4 as the tangible media associated with processor 58, the software may reside in a number of different processors, including processors of the surgeon's console 52, patient side cart 54, vision cart 56, and/or processor 58. Hence, the software may run on one or more processor circuits or processor boards that are physically mounted to one or more of the components of the robotic surgery system 50 in any of a wide variety of centralized or distributed data processing system architectures. Similarly, the software may be written as a single monolithic code, but it will often be broken down into a series of subroutines, with differing portions of the code optionally running on differing processor boards. The functionality attributed to modules described herein will often be implemented as software (including software code embodied on tangible media 59), hardware (including a processor circuit of processor 58 or one of the other processor boards of robotic surgical system 50), and/or a combination of software and hardware suitable for the ascribed data processing tasks.

FIGS. 5A, 5B, and 5C show a patient side cart 22, an 8 mm shaft surgical tool 62, and a 5 mm shaft surgical tool 64, respectively. Surgical tools 62 and 64 are examples of surgical tools 26. The patient side cart 22 shown provides for the manipulation of three surgical tools 26 and an imaging device 28, such as a stereoscopic endoscope used for the capture of images of the site of the surgical procedure. Manipulation is provided by robotic mechanisms having a number of robotic joints. The imaging device 28 and the surgical tools 26 (e.g., the end effectors 66) can be positioned and manipulated through incisions in the patient so that a kinematic pivotal center 25 (see FIG. 1) is maintained at the incision so as to minimize the size of the required incision. Images of the surgical site can include images of distal ends of the surgical tools 26 when they are positioned within the field of view of the imaging device 28.

As can be understood with reference to FIGS. 1 and 5A, each tool 26 is typically supported by a manipulator 23. The manipulator moves during surgery under the direction of a processor of surgeon's console 16 so as to move an end effector of the tool within the internal surgical site per an input movement command. Manipulators 23 are generally supported by a passive support linkage 27 so as to allow the manipulators and tools to be positioned manually in preparation for surgery. The support linkages 27, sometimes referred to as set-up arms (which include one or more unpowered, lockable set-up joints), also allow the position and orientation of tools to be changed during a procedure, with an assistant 20 typically withdrawing the tool, releasing the set-up joints from a fixed configuration to a manually movable configuration, moving the manipulator 23 to a new and desired location, and again fixing the set-up joints. Joint-based data is provided from both the manipulator 23 and the support linkage 27 to the processor of the surgeon cart 16 for calculation of movement commands in response to the input from the surgeon 18.

Referring now to FIGS. 5B and 5C, tools 62, 64 typically include a proximal end 65 supportable by a manipulator 23, and an elongate shaft 67 that extends from the proximal end to a distal end 69. An end effector 71 is coupled to distal end 69 of shaft 67 by a linkage 73, with the end effector and linkage generally being driven by motors of linkage 23. In alternative embodiments, at least some of the degrees of freedom of the set-up joints may be powered, and/or some of the degrees of freedom of the manipulator may be passive. The pivotal center may be defined by a parallel linkage structure of manipulator 23 (encompassed within the term remote center linkage), or a passive joint of the manipulator may allow for natural or environmentally imposed pivoting of the tool about the aperture into the patient. Still further alternatives are possible, including redundant-joint driven linkages, which allow a calculated remote center of pivotal movement to be provided.

Referring now to FIG. 6, a method 110 for measurement using robotic system 50 can be understood. The measurement may be initiated by selecting the measurement mode 112 using a foot pedal, pull down menus, an auxiliary input device (such as a keyboard, mouse, or the like), verbal command to the robotic system or an assistant, or any of a wide variety of alternative approaches. A measurement marker or other indicia may be superimposed 114 on a measurement tool. Where only one tool will be used to perform a measurement, it is helpful for the system user to have a visual indication regarding which of the tools is the measurement tool. Similarly, it may be helpful to have an indication that both tools will be used for the measurement, and/or for the measurement location on the tool to be identified (so that the user does not measure from the pivot point of the jaws, for example, when the system will calculate the offset from a distal tip of engagement surfaces between the jaws). The user may select or change which tool is used as the measurement tool, so as to designate a tool controlled by the dominant hand (the right hand of a right-handed surgeon, for example) as explained in more detail below. While measurements will often be described with reference to input from a single user controlling one or two instruments, coordinated motion of more than 2 instruments will optionally be employed, particularly when designating three or more locations, when simultaneously configuring tissue at three or more locations for measurement, and/or the like. Embodiments of the systems and methods described herein that employ three or more tools may benefit from input devices that accommodate simultaneous three dimensional input from multiple system users. For example, a dual surgeon's console arrangement can be used to facilitate the collaboration of two surgeons while they control three or more instruments at once.

To actually take a measurement, a system user will typically manipulate a master controller 116 (e.g., control device 36 in FIG. 2) so as to indicate a tissue location with a measurement tool. The system user may optionally engage the tissue at the location, such as lightly touching the tool to the tissue, palpating the tissue, or even grasping and reconfiguring the tissue. Alternatively, the user may bring the tool to a location close enough to the tissue to be an accurate point designation without actually touching the tissue. The use of the tool can allow the user to be confident that the point designation is valid even without touching the tissue, and verifying the location marker positioning on the marker can further enhance marker accuracy, repeatability, and confidence. Nonetheless, making contact with tissue can provide a useful visual cue to confirm that the instrument tip is at the intended depth.

Once the measurement marker of the tool is at the desired location, the user may then actuate an input (such as by opening and/or closing a handle of a master controller, optionally the one master controller associated with the measurement tool or a different master controller, by depressing a foot pedal, or the like) so as to designate a tissue location 118 to the system. The system can then superimpose a marker of the designated tissue location 120. Erroneously designated locations may optionally be removed by an alternative input, such as by actuating the handle of the master controller associated with the non-dominant hand. Note that the superimposing of markers on the image of the stereoscopic display and determining the tool location data may be implemented using processor 58 as shown in FIG. 4, by a processor of the vision cart 56, by a processor of the surgical robot 54, or by an alternative processor structure. The tissue location information may include and/or make use of information provided from robotic data output from patient side cart 54, with the robotic data often comprising joint-based data from the surgeon's console 52 and from the patient side cart 54. Three-dimensional position data corresponding to the designated tissue location will often be based at least in part on stereoscopic or other image capture devices. In some embodiments, at least some of the information regarding locations of the tools within the surgical site may be provided by processing the data displayed as images of the tools and surgical site displayed to the system user (as more fully described in co-pending U.S. patent application Ser. No. 12/428,691 (filed Apr. 23, 2009), previously incorporated herein by reference, and/or from any of a wide variety of alternative image-based tool tracking systems.

As noted above, the interaction between the tissue and tool during indication of the tissue location with the robotic tool may range from being near (but not touching) the tissue to actively grasping and reconfiguring the tissue. For example, the tool may reposition the tissue structure to be measured, optionally grasping the tissue, straightening the tissue structure, bringing the structure out from behind an intervening tissue or other object and into the field of view of the camera, or the like. In some embodiments the tool will palpate the tissue, optionally so as to indicate a location below a soft tissue surface, enhance accuracy and repeatability of designation of the measurement location(s), and/or the like. In embodiments where the tool is separated slightly from the tissue surface, a variety of image matching techniques can be combined with data from a calibrated stereoscopic camera (e.g., one calibrated using the structures and techniques described in U.S. patent application Ser. No. 12/415,377 (filed Mar. 21, 2009), the full disclosure of which is incorporated herein by reference, so as to determine a 3-D location of the tissue surface and/or structure. In general terms, the location of a surface, feature, or structure in left and right images, together with the calibration information, can be used to determine the horizontal position (X-Y) of the structure relative to the camera and the distance (Z) between the camera and that surface, feature, or structure. As described in more detail in U.S. Patent Application No. 61/204,082 (filed Dec. 31, 2008), the full disclosure of which is incorporated herein by reference, selective robust image matching between the left and right stereoscopic images can efficiently and robustly identify corresponding left and right images of one or more selected points on a tissue surfaces in the surgical field. Related techniques can be used to determine the location of the tool, optionally with the assistance of appropriate tool markers, as more fully described in U.S. Patent Application No. 61/203,975 (filed Dec. 31, 2008), also incorporated herein by reference.

In the exemplary sparse image matching technique, points of interest from a first image are identified for matching to the second image. Such points of interest might be identified by locating a tool tip or the like over the desired location or point on the tissue surface, optionally such that the tip is disposed on the point as seen in the dominant eye of the system user though the tool remains slightly separated from the tissue surface (more specifically between the tissue surface and the camera). The selectively identified points of interested can be matched to the second image (optionally as shown to the non-dominant eye) with selective matching. The selective matching can match the selectively identified points with matching that is appropriate to the local characteristics of the image, which may include region matching, feature matching, feature interpolation, and/or interpolation of previously matched points. For example, regions can be identified in response to the selected points of interest, and the regions may be used to match the selectively identified points of interest. Region matching scores can be determined when the regions are matched, and for regions that are not sufficiently matched, the features of the insufficiently matched regions can be determined and matched to the second image such that these features are used to match the points of interest to the second image. This use of feature matching in response to insufficient region matching provides a more robust match while still providing good matching speed. Soft epi-polar constraints and/or focus constraints can be used to evaluate the matched points of interest, particularly when the surgical field includes interfering objects at different depths from the tissue. Interpolation may be used when confidence scores for feature matching are below a threshold value or bad points are excluded by the constraints.

As an example, the point of interest might be identified with reference to a pixel location of the right image of a tissue. The output of the image matching may generally include the corresponding pixel location of the tissue surface as seen in the left image. Each pixel location effectively provides an associated X-Y location for that eye, with a parallax offset between the coordinate systems generally allowing the depth to be determined per the camera calibration data. The matching may occur while to tool is at the indication location (or if it is in the way, after it moves from between the tissue surface location and camera) and the location marker may snap from the tool to the tissue surface. Alternative location indication techniques and systems might also be employed, such as determining an array of matched tissue surface locations in a region or window around the tool, determining a location of the measurement location on the tool, and snapping the marker to the tissue surface where it is closest to the tool.

Continuing on with exemplary measurement method 110 as shown in FIG. 6, after the first tissue location is designated the system user may then manipulate the master controller to move the tool to the next desired tissue location 122. As the tool moves in the stereoscopic image presented to the system user, a stretch line is superimposed on the image of the site from the prior designated tissue location to the moving measurement tool, and more specifically to the marker which remains superimposed on the measurement tool 124. Increment data may be displayed 126 during movement of the master controller, including the stretch line length, and the like. Optionally, a total length (including prior offsets between pairs of designated tissue locations) may also be superimposed on the image.

When superimposing markers and the like on tissue, on robotic structures (such as tools), or on other structures as shown in the image, it will often be advantageous to have the markers appear at the same depth at which the underlying structure appears in the stereoscopic images presented to the system user. While a variety of methods may be used for matching locations in the left and right images so that the markers appear at the same depth as an underlying tissue or other structure, the particularly efficient and robust image matching technique described in co-pending U.S. Patent Application No. 61/204,082, previously incorporated herein by reference, has significant advantages.

Once the measurement tool has engaged and manipulated (as desired) the next tissue location, the user can actuate the input so as to designate the tissue location 128. Based on data extracted from the image (optionally, also making use of joint-based or kinematic robotic data to verify the image-based location information), the offset data can be updated 130 and another marker superimposed on the designated tissue location 132. In some embodiments, the stretch line may only appear between the immediately prior designated location and the moving tool, while alternative embodiments may fix the stretch line segments so that the user can see the overall contour that has been defined by multiple designated tissue locations. The designated tissue locations may, as mentioned above, be extracted from tool tracking data obtained by image processing of the stereoscopic images presented to the system user, and the data will often include 3-D offsets between tissue locations. The data may define a 3-D polyline that includes a series of straight line segments connecting designated tissue locations so as to define a contour. Alternative embodiments may employ splines or other curving lines between designated points, or they may project the lines onto the underlying or nearest tissue surface as identified by image matching techniques. If the system user indicates this is the last location 134 (and/or the system determines it is the last location such as by effectively enclosing an area, reaching the pre-identified number of line segments of interest, or the like) the final measurement may be displayed 136, with the display often again being superimposed the surgical site. Alternative embodiments may employ display data which is set off from the tissue image, either outside the tissue image window, on a separate display, on a separate window within the tissue image display, or the like. The user may indicate that it is the last location by double clicking the master control handles, depressing the foot pedal, actuating an alternative handle (or both handles), or the like. If the location is not identified as the last location, the system may allow the user to again manipulate the master controller and designate additional tissue locations 122, and so on.

System 50 and method 110 (including variations thereof) can enable accurate in vivo 3-D measurements to be obtained during minimally invasive surgical procedures. These systems and methods can leverage robotic surgical systems that have been developed (including the da Vinci® Surgical System commercially available from Intuitive Surgical, Inc. of California). Alternative embodiments may be based on or added to robotic surgical systems are now being developed or that are developed in the future. The techniques and systems described herein may involve tracking of tools using image data and augmenting the surgical field with graphical information (and particularly with 3-D overlay graphics that depict a measurement cursor or marker, either on a measurement tool or independent of any measurement tool). The measurement location and tool indicators, stretch line and other measurement markers, and output graphics (such as an interactive 3-D numeric readout) can appear on tissue or other structures within the image field, outside the image field but within the surgeon's display, and/or on another auxiliary display system.

In exemplary embodiments, the 3-D overlay visuals may be rendered using a calibrated stereo camera model that is consistent with the surgeon's stereo endoscopic view of the anatomy, so that the 3-D indicator visuals (including points, lines, and/or numerical readouts) are rendered so as to appear coincident in three dimensions with the anatomy or other structures in the field of view. By refreshing the overlay visuals at a sufficient rate, the surgeon may interactively position 3-D markers by effectively steering the markers with the master control input devices 36 on the surgeon's console 16 (see FIG. 2). Moving the tool with the marker allows the surgeon to interact with the tissue when taking measurements, which may avoid placing the marker at a location in space which is inconsistent with the tissue surface, either floating in space above the tissue surface toward the stereoscopic image capture device, or at a location effectively within a tissue surface beyond the tissue location in 3-D space away from the image capture device.

Preferably, the Cartesian position of the instrument tip (or other measurement location) will be determined sufficiently accurately so as to manipulate the 3-D markers for the desired measurement. The Cartesian position will often be determined in the camera reference frame, and the control over the tools provided by the robotic system will facilitate moving the marker in a predictable manner relative to the instrument tip, background tissue and other structures, and the like. To provide the desired accuracy of marker position and movement, image-based tool tracking systems which track the tool position in the camera view can be employed. In alternative embodiments, the robotic manipulator supporting the instrument (optionally the manipulator supporting the camera or other image capture device) may be calibrated (typically prior to initiation of surgery) so as to minimize instrument tip position error in the camera reference frame.

By combining 3-D overlay visuals with accurate information regarding the instruments, a variety of measurement interactions may be achieved. Many of these measurement interactions involve using master-slave following of the instrument tip per movement commands input by the system user to the robotic surgical system. In addition to effecting movement of the tool, movement of a 3-D marker or cursor superimposed on the display of the surgical site, and specifically on the tip of the tool, causes the marker to closely follow the instrument tip. As the instrument tip or distal end of the tool touches anatomy, the 3-D marker will be sufficiently coincident with that anatomy so as to allow accurate location designation. Using a button press or foot switch, the system user samples the current position of the marker and instrument tip. Additional movement of the instrument and button presses may be used to sample a sequence of points. The cumulative Euclidean distance between those sampled points can be interactively computed and displayed to the user. A number of measurement modes may be supported, often using this fundamental instrument measurement interaction. Hence, the surgeon may measure the distance between two or more points in a series. These points may form an open or closed contour. Other quantities may be derived from these points, such as the surface area of a closed contour or the volume of a convex hull of points. The interaction for measuring a long contour may be expedited by automatic sampling of points at regular distance or time intervals, or the like.

In addition to polygon or poly-line representations, spline or similar models can be fit to the data to better approximate the structures of tissue due to its natural tendency towards smoothness. The fitting process can potentially remove some jittering of the hand motion when specifying points. Covariance matrices of a 3-D point can be derived from viewing geometry to account for the non-homogeneity of the error in points (typically resulting in more error in the viewing direction) and may benefit the fitting process.

Points may, in some modes, also be used to efficiently define two-dimensional or 3-D parametric geometric shapes, such as an ellipse, an ellipsoid, soft objects, as used in computer graphics, and the like, optionally using only a few point locations. Properties of the geometric shapes can be derived or determined, such as by calculating the circumference and area of a two-dimensional shape, the volume of a 3-D shape, or the like.

The methods and systems described herein may often be implemented by adding additional software modules to an appropriately equipped robotic surgical system, particularly such a system already having image-based tool tracking capabilities. The virtual measurement software tools described herein may support a variety of modes of interaction between the system and the user, as well as different modes for measurement computation. One such class of interactions between the system user and the computation module may include a single-handed measurement, in which (for example) a single tool is used for measuring the length of a 3-D contour, the surface area of a closed contour, and/or the like. Another type of interaction between the system user and the measurement calculating module may involve the use of two hands and two associated tools, with the tools optionally performing grasping and manipulation during measurements. These measurement tools may generally rely on the ability of a telesurgical system to accurately determine the position of a tool end effector or instrument tip, as well as to accurately highlight or draw on that position in an overlay visual on the display of the system such that it appears coincident with the instrument tip in a 3-D stereoscopic view.

Referring now to FIG. 7, an exemplary data sampling or designating method 150 may be used for sampling a contour or designating locations. The system user will often use their dominant hand for controlling the measurement instrument tip location, and they may grasp or actuate a handle with their non-dominant hand for adding or removing samples. For example, a right-handed system user will typically use their right hand for steering of the tool and their left hand for designating and/or de-designating locations. For method 150, the right hand is assumed to be the dominant hand and the left hand is assumed to be the non-dominant hand. This may be changed using set up menus, pull down menus, or the like.

Throughout sampling or designation method 150, the right hand may remain in a closed grasp, so that the instrument graspers or jaws remain closed. This may configure a tool having jaws in an advantageous configuration for touching tissue and designating points of interest, and it may optionally identify the measurement tool to the system. The tool jaws are typically closed by closing the paddles of a handle of the master controller. When the right hand grasps the handle 152 the tool is able to add points 154 by briefly grasping with the left hand 156 so as to also close that handle. Using the non-dominant hand for adding and removing points inhibits unintended motion of the dominant hand, which could otherwise adversely affect the accuracy of tool positioning. In alternative embodiments, a foot pedal or additional buttons on the surgeon's console may be provided, preferably such that the input actuation does not interfere with controlled placement of the tool. When the right hand is opened 158, the tool is able to remove points 160 by grasping with the left hand 162.

The system's interaction with the user is such that there is always a point which interactively tracks the instrument tip when in the measurement mode. The system user controls the instrument to position this point to be coincident with the anatomy to be measured. Upon settling on a location, the point may be deposited by grasping with the left hand, which effectively drops the point or point marker at the current location and adds a new point to be interactively moved. To further improve the user interface experience, a poly-line visualization displays a connection between each pair of points in the sequence up to and including the last point at the instrument tip. This provides additional visual confirmation for aligning the direction of the contour relative to the anatomy to be measured. Note that the flow chart of sampling method 150 assumes that 3-D visualization of the measured poly-line is to be redrawn for the operator any time that the poly-line has been changed.

Referring now to FIG. 8, a class diagram of the contour-related measurement tools is shown, as well as the inheritance of behavior between those tools. These tools respond to button press events and motion events so as to handle placement of the measured points. The tools support the same point placement interaction modes shown in FIG. 7, but they may differ in the way that they process the series of points to produce measurement text for the display. The supported interaction modes include point-to-point placement for measuring the distance between two points, poly-line point placement for measuring an arbitrary contour, and continuous point placement for producing a spatially regularly sampled measurement.

The contour measurement tools also support a continuous sampling mode or location designation method 180, as illustrated in FIG. 9. Method 180 produces regularly spaced samples. The operator may optionally specify a desired sampling tolerance, which determines the minimum spacing between two sample points. A tolerance of between 0.1 millimeter and 20 millimeters may be useful, with a 1 millimeter tolerance often being workable, such that the 1 millimeter tolerance may be used as a default value. Left and right grasping may be used to add or remove points in a manner generally analogous to that described above, with a distance measurement step 182 being used to determine when the tool has been moved sufficiently far so as to justify adding a new sample. Alternative methodologies for sampling may depend on time-based periodic sampling, changes in differential spatial quantities (for example, with samples acquired in response to a continuity and/or curvature of the tool path), or some combined metrics based on spatial and temporal quantities (for example, with samples acquired in response to a velocity and/or acceleration of the tool), or the like.

Referring now to FIGS. 10A and 10B, the contour tools may generally rely on a poly-line 3-D object. This may be used to store a sequence of sampled 3-D points from which to compute length and area measurements. The open contour tool can produce its measurement value using a ComputeLength method of the poly-line 3-D object using the following equation:

$\begin{matrix} {l = {\sum\limits_{2}^{N}{{\rho_{i} - \rho_{i - 1}}}}} & {{Equation}\mspace{14mu} 1} \end{matrix}$

The closed contour tool produces its measurement using Equation 1, and then it adds the length of the segment connecting the last point in the sequence to the first point in the sequence. The closed contour area is computed by approximating the enclosed surface area, optionally using a tessellation of triangles. The area may then be obtained by integrating the area of each triangle. One approach for tessellating the surface is to use a triangle fan with a fixed point at the centroid of the 3-D contour. This works particularly well for convex and nearly convex input, which represents the majority of the contours to be measured.

Embodiments of the invention may also allow a two-handed instrument interaction referred to as hand-over-hand measurement. This can be implemented so as to enable the system user to measure a length of tissue while manipulating the tissue with two grasper instruments, with some or all of the manipulation occurring in the view of the image capture device. For such measurements, a point along the grasper of each tool may be tracked with the Euclidian distance between those points being used to measure the length of tissue currently being grasped. The interaction also allows the system user to sequentially accumulate the length of tissue grasped between the tools. The distance between the tools is automatically sampled and accumulated based on articulation of the tool grasper. Due to the nature of hand-over-hand interactions with the robotic surgical system, one hand can be assumed to be grasping (and thus designating) a new location. Once the new location is grasped and the other hand releases the tissue, the system automatically samples and accumulates the distance between the instruments. This sampling condition is convenient in that it allows the user to grasp and regrasp before committing to the accumulated measurement, such that when a tissue is released from a right-hand tool and the surgeon is reaching along beyond the left-hand tool, the surgeon may move the overall tissue around or move other tissues out of the way before designating the new grasping location by releasing the left-hand tool. Additionally, the system user may have the opportunity to straighten or even slightly stretch the tissue being measured to best approximate the linear segment length that is desired to be sampled.

Referring now to FIG. 11, a hand-over-hand data sampling method 200 allows the user to grasp, manipulate, and move tissue within and/or through the field of view of the image capture device while accumulating a total measured length. The interaction provides an intuitive two-handed measurement paradigm, akin to alternatingly using each hand to pull in a long rope. The interaction does not impose limits on the direction or length of measurement. An operator may measure an arbitrarily long or curvy specimen by making a sequence of piecewise linear measurements. One example use of this measurement interaction is for measuring out a length of bowel in a gastrointestinal procedure. In hand-over-hand sampling method 200, the interaction between the system user and the system has been designed so as to allow the system user to use an alternating pattern of grasping with one hand and measuring with the other hand. The measurement is initiated with the operator grasping the specimen to be measured with one hand or the other. The non-grasping hand becomes the measuring hand. The system continually computes and displays the computed distance between the tools associated with the right and left hands and master command input devices as well as a running total of prior measurements. Before releasing the grasping hand 202, the non-grasping hand is free to grasp and release multiple times before settling on the desired grasp to commit the measured length. Upon releasing the grasping hand 202, the measurement is committed and the relationship between the hands is switched. Committing the measurement involves adding the computed distance between the two tools to a running total 204. The former measuring hand is then left grasping the specimen, and the former grasping hand is now measuring tool free to designate a new location due to the switching of roles 206.

FIG. 12 is a screen shot graphically showing a point-to-point single line segment measurement using image data. Displayed image 220 shows a tool 222 on which a marker 224 has been superimposed. A marker 226 is shown at a previously designated location, and a stretch line 228 extends between the previously designated location and the marker on the tool. A numerical graphic 230 showing the length of the stretch line is provided offset from the stretch line and within a field of view of the imaging device. Various colors may be used for the displayed stretch line 228 to make it visible against background tissue. In embodiment illustrated by FIG. 12, stretch line 228 is bright green. Likewise, various colors may be used for the displayed markers.

Referring now to FIG. 13, a poly-line measurement is schematically illustrated. A tool 240 has previously been used to designate two tissue locations 242, 244, and displayed markers have been left at those locations after the tool has moved on. Line segments 246 remained fixed between previously designated locations. A stretch line 248 moves with tool 240 and specifically extends between the immediately previously designated location 244 and a measurement location 250 on the tool. A marker 252 is superimposed on the tool at the tool's measurement location so as to appear to move with the tool during measurement. Note that the marked locations need not (and often will not) lie in a line, within a single plane, or the like. Once the tissue locations are designated, the displayed markers may remain with the tissues when the camera moves so as to view an alternate portion of the tissue being measured.

Referring now to FIG. 14, an exemplary embodiment of an enclosed poly-line measurement can be seen. Note that a circumference and/or area of a tissue structure of interest may be displayed, with the tissue structure here comprising a mitral valve annulus. Differing colors may be used for the different displayed markers or lines. For example, area border lines 254 may be shown in yellow, and tessellation lines 256 extending from a center 258 of the area to each of the displayed markers 226 may be shown in white. The tessellation lines may be used in calculating the area within border lines 254.

An exemplary hand-over-hand measurement method can be understood with reference to FIGS. 15A and 15B. Measurement tool 260 moves along flexible tissue or other structure FT (here a measurement tape), generating an output that shows a measurement distance between measurement tool 260 and grasping tool 262. Once the desired location along flexible tissue FT has been identified and the tissue has been appropriately straightened and/or stretched, the measurement tool 260 may remain in a closed grasping mode while grasping tool 262 is released, the action that updates the cumulative distance measurement to include the latest separation between the tools. The separation distance may again be shown with the roles of the two tools switching, with previous measurement tool 260 now being the grasping tool, and so on.

The illustration of FIG. 15B shows verification of hand-over-hand measurement interaction using a tape measure. A line segment is overlaid in three dimensions between the instrument graspers so as to represent the length being measured. A text message is interactively displayed at the mid point of the segment so as to indicate intermediate and cumulative measured lengths.

Additional embodiments may combine a number of the techniques and systems described above with a still stereoscopic image so as to facilitate measurements of offsets, areas, volumes, aspect ratios, and the like. For example, it may be desirable to obtain measurements from moving tissues, particularly for measurements of tissue structures of the heart during closed-chest beating heart procedures. So as to facilitate accurate measurements during such physiological movement, the processor can freeze the stereo video images presented to a system user (such as the stereoscopic image presented to one or more surgeon in the surgeon's console, or the two dimensional image presented to an assistant or proctor in an associated display). The image may be frozen per an input from a system user in preparation for designating tissue locations, or in response to an input indicating that the robotic tool is disposed at or adjacent a first tissue location. Regardless, the same (or a different) system user can then identify one or more tissue locations in the frozen image. Optionally, tissue locations can by identified by using a master input device of the surgeon's console to steer a 3d cursor to the desired location of the tissue image. Alternatively, the systems user may simply designate a location in one of the two frozen stereoscopic images. In either case, the cursor may snap to the tissue surface based on a location of the cursor in one of the stereoscopic images when a tissue designation command is received by the processor. When the desired tissue locations have been entered in the frozen image, three dimensional offsets and measurements may be determined from the three dimensional image data as described above. While all of the tissue locations may optionally be indicated using a cursor or the like, indication of at least the first location with a robotic tool may help to stabilize the local tissue. For measurements of a beating heart and/or other cyclically moving tissues, a time series images may be captured and used to generate a sequence of measurements at different stages of a tissue movement cycle. Hence, such systems and methods can (for example) capture a series of cyclic pumping states of the heart and perform measurements of those states to enhance diagnosis and treatment of a variety of heart conditions.

While exemplary embodiments have been described in some detail for clarity of understanding and by way of example, a variety of modifications, adaptations, and changes will be obvious to those of skill in the art. Hence, the scope of the present invention is limited solely by the appended claims. 

1. A method for measuring tissue, the method comprising: acquiring an image of the tissue so as to generate corresponding image data; indicating a first tissue location with a first robotic tool; superimposing a first graphical indicator on the image of the tissue at the first location; and generating a measurement between the first graphical indicator and a second tissue location using the image data.
 2. The method of claim 1, wherein the image of the tissue comprises left and right stereoscopic images shown on a stereoscopic display, wherein the first tool is guided to the first tissue location by a system user with reference to the stereoscopic images, the first tool and display being included in a telesurgical system, and further comprising inputting at least one tissue designation command, by the user, when the first and second locations are engaged.
 3. The method of claim 2, wherein the system includes a stereoscopic image capture device transmitting stereoscopic imaging data to the stereoscopic display, wherein the graphical indicator comprises a three dimensional indicator superimposed on the stereoscopic images of the tissue so as to appear coincident in three dimensions with the first location, wherein the system determines the first location of the superimposed indicator using the stereoscopic imaging data of the first tool.
 4. The method of claim 2, wherein the first tool indicates the first tissue location and the first tool also indicates the second tissue location, the first and second tissue locations being indicated sequentially.
 5. The method of claim 2, wherein a second robotic tool indicates the second tissue location the first and second tissue locations being indicated simultaneously.
 6. The method of claim 1, wherein the image encompasses a plurality of robotic tools including the first tool, further comprising superimposing a graphical tool measurement marker on the display coincident with the first tool while guiding the first tool to the first tissue location using the image.
 7. The method of claim 6, further comprising superimposing a moving line extending between the first and second locations while guiding the first tool to the first location.
 8. The method of claim 1, further comprising robotically indicating at least one additional tissue location, the measurement comprising a three dimensional offset distance between a sequential pair of tissue locations, and determining a cumulative total of a plurality of offset distances.
 9. The method of claim 1, wherein the first tool grasps and manipulates the tissue at the first tissue location, and further comprising alternatingly engaging a plurality of additional tissue locations with the first tool and a second robotic tool by grasping tissue at the locations in jaws of the tools and summing the distances between the locations so as to measure a hand-over-hand length along the grasped tissue.
 10. The method of claim 1, further comprising indicating a plurality of additional tissue locations defining an enclosed area, wherein the measurement comprises an area measurement.
 11. The method of claim 1, further comprising palpating the first tissue location with the first tool.
 12. The method of claim 1, wherein the tool manipulates the tissue so as to move the tissue to a measurement configuration for indicating the first tissue location.
 13. The method of claim 1, wherein the first tissue location is indicated by moving the first tool toward the first location and snapping the tissue location from the tool to a tissue surface adjacent the tool using stereoscopic image data of the tissue surface.
 14. The method of claim 1, wherein the tissue comprises a physiologically moving tissue, wherein the image comprises a still stereoscopic image of the moving tissue acquired while the first tool is indicating the first tissue location, and wherein the second tissue location is indicated by positioning a three dimensional graphical indicator superimposed on the still stereoscopic image so as indicate the second tissue location.
 15. A robotic system for measuring tissue, the system comprising: an image capture device orientable toward a surgical site, the image capture device in use generating image data corresponding to an image of the tissue at the surgical site; a display coupled to the image capture device so as to show the image to a system user; a first robotic tool; an input for designating tissue locations indicated by the first tool; a processor coupling the input to the display so as to superimpose a first graphical indicator on the image of the tissue at a first designated tissue location, and so as to determine a measurement between the first graphical indicator and a second tissue location using the image data.
 16. The system of claim 15, wherein the image capture device comprises a stereoscopic image capture device, wherein the display comprises a stereoscopic display, and further comprising a master controller coupled with the robotic tool for receiving movement commands from a system user to guide the first tool to the first tissue location with reference to left and right stereoscopic images shown on the display, and wherein the processor superimposes a graphical tool measurement marker on the image coincident with the first tool while the user guides the first tool to the first tissue location.
 17. The system of claim 16, wherein the processor is configured to receive tissue designating commands sequentially from the user so as to facilitate indication of the second tissue location with the first tool.
 18. The system of claim 16, wherein the processor is configured to receive a tissue designating command from the user so as to simultaneously indicate the first tissue location with the first tool and the second tissue location with a second robotic tool.
 19. The system of claim 16, wherein the processor couples the input to the display so as to superimpose a moving line extending between the first and second locations while the user guides the first tool to the first location.
 20. The system of claim 19, wherein the processor is configured to determine an offset display location such that the measurement is displayed superimposed on the tissue image and separated from the line.
 21. The system of claim 15, wherein the processor couples the input to the display so as to receive additional input designation commands indicating additional tissue locations, so as to determine a three dimensional offset distance between sequential pairs of tissue locations, and so as to sum the offset distances and superimpose a resulting cumulative measurement on the image.
 22. The system of claim 15, wherein the first tool and a second tool each comprise jaws, wherein the tissue designation input comprises jaw articulation inputs for the jaws so that processor is configured to measure the plurality of offset distances by summing the offset distances in a hand-over-hand length measurement along the tissue.
 23. The system of claim 15, wherein the processor couples the input to the display so as to receive additional input designation commands so as to define an enclosed area, wherein the measurement comprises an area measurement.
 24. The system of claim 15, wherein the tissue locations comprise discrete locations bordering the area, with each tissue location having an associated designation command.
 25. The system of claim 15, wherein the image capture device comprises a stereoscopic image capture device, wherein the processor determines a three dimensional location of a tissue surface in response to the image data, and wherein the processor designates the first tissue location by snapping the graphical indicator from the first tool to the tissue surface.
 26. The system of claim 15, the tissue comprising a physiologically moving tissue, wherein the image comprises a still stereoscopic image of the moving tissue, and further comprising a three-dimensional input device coupled to the display by the processor so that a three dimensional graphical indicator superimposed on the still stereoscopic image is positioned using the input device so as to indicate the second tissue location.
 27. A robotic system for measuring physiologically moving tissue, the system comprising: a stereoscopic image capture device orientable toward a surgical site, the image capture device in use generating video image data corresponding to an image of the tissue at the surgical site; a display coupled to the image capture device so as to show the image to a system user; an input for designating tissue locations; a processor coupling the input to the display so as to position a three dimensional graphical indicator superimposed on a frozen stereoscopic image of the tissue when a first tissue location has been designated, and so as to determine a measurement between the graphical indicator and the first tissue location. 